Lengthened ring use

• If the ring has been left in place for up to 4 weeks (rather than the recommended 3 weeks), contraceptive efficacy is not reduced. Advise the woman to remove the ring and insert a new ring after one ring-free week.
• If the ring has been left in place for more than 4 weeks (rather than the recommended 3 weeks), contraceptive efficacy may be reduced. Advise the woman to rule out pregnancy before inserting a new ring.
• If a woman has not used the ring as recommended and has no withdrawal bleed in the ring-free week, advise her to rule out pregnancy before inserting a new ring.

Lengthened ring-free interval

• Advise the woman to insert a new ring as soon as she remembers.
• Advise her to use additional barrier contraception for the next 7 days.
• If the woman had sexual intercourse in the ring-free interval, advise her to rule out pregnancy and consider emergency contraception (if appropriate) before inserting a new ring.

In depth

• Advise the woman to check the presence of the ring regularly (for example, pre-coitally) as there are reports that it may be expelled if it is not inserted properly, while removing a tampon, during sexual intercourse, or in severe or chronic constipation.
• Prolonged expulsion may lead to contraceptive failure and/or breakthrough bleeding.
• Deliberate removal of the ring is not recommended.
• If the ring is removed or expelled and left outside the vagina for less than 3 hours, rinse the ring with cool to lukewarm water and reinsert it as soon as possible, within 3 hours.
• If the ring is expelled and left outside the vagina for more than 3 hours, the recommended action depends on the week of use.
• During the first or second week of use, the woman should reinsert the ring as soon as she remembers. Additional barrier contraception should be used until the ring has been in the vagina continuously for 7 days. Assess the need for emergency contraception.
• During the third week of use, the woman should discard the ring, and either:
• Insert a new ring immediately, which will start a new cycle. Advise her that breakthrough spotting or bleeding may occur.
• Have a withdrawal bleed, and insert a new ring no later than 7 days from when the previous ring was expelled.

In depth

• If the ring is found to be broken during use, advise the woman to remove it, reinsert a new ring as soon as possible, and use additional barrier contraception for the next 7 days.
• If it is suspected that unprotected sexual intercourse has taken place in the previous 5 days, emergency contraception should be considered — see the CKS topic on Contraception - emergency.

In depth

• If pregnancy occurs with a combined contraceptive vaginal ring in situ, the ring should be removed.

In depth

• If irregular bleeding (spotting or breakthrough bleeding) occurs after previously regular cycles while the ring has been used as recommended, then consider other non-hormonal causes. Consider excluding pregnancy and refer the woman according to clinical judgement.
• Some women do not experience a withdrawal bleed in the ring-free week.
• If the ring has been used as recommended, it is unlikely the woman is pregnant.
• If the ring has not been used as recommended prior to the first missed withdrawal bleed, or if there are two missed withdrawal bleeds, advise the woman that pregnancy should be ruled out before use of the ring is continued.

In depth

• The efficacy of the ring may be reduced by liver enzyme-inducing drugs, and non-liver enzyme-inducing antibiotics (excluding amoxicillin and doxycycline which do not appear to be affected).
• If a woman is taking a liver enzyme-inducing drug, advise her to use additional barrier contraception for the duration of treatment and for 28 days after its discontinuation, or choose another method of contraception. If the drug treatment runs beyond the 3 weeks of her cycle, advise her to insert the next ring immediately without a ring-free week.
• If a woman is taking non-liver enzyme-inducing antibiotics (excluding amoxicillin and doxycycline), advise her to use additional barrier contraception for the duration of treatment and for 7 days after their discontinuation. If the drug treatment runs beyond the 3 weeks of her cycle, advise her to insert the next ring immediately without a ring-free week.

In depth

The management of these problems is similar to that for women using a combined oral contraceptive (COC). For more information, see Diarrhoea or vomiting, unscheduled bleeding, surgery (on a COC). Note: diarrhoea and vomiting do not affect the bioavailability of the combined oral contraceptive patch.